COI Request Form

CERTIFICATE OF INSURANCE REQUEST FORM

IMPORTANT INSTRUCTIONS - PLEASE READ!

Below is the new online version of the Florida Region Certificate of Insurance Request Form. This form can be used to request insurance certificates for up to four of the facilities that you plan to use during the season. If you need more than four certificates, please complete this form as many times as necessary to fulfill the requirements of your facilities.

Please note that USAV insurance certificates are valid from Nov 1st to Oct 31st of the respective year. Insurance certificates for the new season will be compiled and distributed after the Nov 1st activation date. Note: The language on the insurance certificate cannot be modified regarding the "Additionally Insured" clause and we cannot provide a copy of the insurance policy, only the Certificate of Insurance with the summary of coverages.

All certificates will be e-mailed to the respective club. Please allow 5-7 days during the peak of the registration season (Dec-Feb) for the certificates to be prepared and e-mailed to your club.

Please contact the Region Office at (352) 742-0080 if you have any questions on this form.

Florida Region Online Certificate of Insurance Request Form

CLUB INFORMATION
Club Name:
Contact Name:
Mailing Address:
City/State/Zip:
Telephone:	Fax:
Contact E-Mail:
Date Certificate Needed:
CERTIFICATE HOLDER INFORMATION - #1
Facility Name:
Mailing Address:
City/State/Zip:
Telephone:
E-Mail Address:
Certificate Type:
Reason For Certificate:
CERTIFICATE HOLDER INFORMATION - #2
Facility Name:
Mailing Address:
City/State/Zip:
Telephone:
E-Mail Address:
Certificate Type:
Reason For Certificate:
CERTIFICATE HOLDER INFORMATION - #3
Facility Name:
Mailing Address:
City/State/Zip:
Telephone:
E-Mail Address:
Certificate Type:
Reason For Certificate:
CERTIFICATE HOLDER INFORMATION - #4
Facility Name:
Mailing Address:
City/State/Zip:
Telephone:
E-Mail Address:
Certificate Type:
Reason For Certificate:

Please call the Region Office at (352) 742-0080 if you have any questions on this form.